Citation Nr: 0711653
Decision Date: 04/19/07 Archive Date: 05/01/07
DOCKET NO. 02-07 499 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Washington,
DC
THE ISSUES
1. Entitlement to a disability rating greater than 20
percent for spondylolisthesis, grade II, with degenerative
disc disease of the lumbar spine prior to October 19, 2004.
2. Entitlement to a disability rating greater than 40
percent for spondylolisthesis, grade II, with degenerative
disc disease of the lumbar spine from October 19, 2004 to
February 10, 2006.
3. Entitlement to a disability rating greater than 60
percent for spondylolisthesis, grade II, with degenerative
disc disease of the lumbar spine since February 10, 2006.
REPRESENTATION
Appellant represented by: Veterans of Foreign Wars of
the United States
WITNESS AT HEARING ON APPEAL
Veteran
ATTORNEY FOR THE BOARD
Anthony M. Flamini, Associate Counsel
INTRODUCTION
The veteran had active service from January 1985 to October
1987.
This matter comes before the Board of Veterans' Appeals
(Board) on appeal from a July 2001 rating decision of the
Department of Veterans Affairs (VA) Regional Office (RO) in
Washington, DC. The case returns to the Board following
remands to the RO in September 2003 and May 2005.
In February 2005, the RO granted an increased rating of 40
percent for spondylolisthesis, grade II, with degenerative
disc disease effective October 19, 2004, which the veteran
appealed. In April 2006, the RO granted an increased rating
of 60 percent for spondylolisthesis effective February 10,
2006.
The veteran testified before the undersigned at a Board
hearing in September 2002. A transcript of that hearing is
associated with the claims folder.
FINDINGS OF FACT
1. From October 20, 1987 to October 19, 2004, the evidence
shows subjective complaints of frequent low back pain and
occasional right leg numbness with pain increasing with
prolonged sitting or standing, pain upon bending forward and
climbing stairs, and objective evidence of fairly normal
range of motion of the lumbar spine; there was no objective
weakness or neurological abnormality, although mild muscle
spasm and tenderness to percussion were noted.
2. From October 19, 2004 to February 10, 2006, the evidence
shows subjective complaints of daily pain with numbness
radiating into the veteran's right leg and recurring
exacerbations about 2 to 3 times per week as well as
objective evidence of a below normal range of motion, with
forward flexion limited to 20 degrees, extension limited to 5
degrees, and rotation limited to 15 degrees in both
directions; there was no objective indication of severe low
back disability with recurring, but infrequent,
exacerbations; there was no evidence of significant
neurological manifestation or evidence of spasm or other
symptoms.
3. As of February 10, 2006, the evidence shows subjective
complaints of daily pain and numbness which increases with
prolonged sitting and flare-ups every 2 weeks as well as a
tingling sensation that radiates down his right leg and foot;
there was no objective indication of weakness, although there
was tenderness and lumbar paravertebral muscle spasm with
forward flexion limited to 20 degrees, extension limited to
15 degrees, and rotation limited to 25 degrees .
CONCLUSIONS OF LAW
1. The criteria for a disability rating greater than 20
percent for spondylolisthesis, grade II, with degenerative
disc disease of the lumbar spine prior to October 19, 2004
have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38
C.F.R. §§ 3.321, 4.1-4.7, 4.21, 4.40, 4.45, 4.71a, Diagnostic
Code 5243 (2006); 38 C.F.R. § 4.71a, Diagnostic Code 5293
(2002).
2. The criteria for a disability rating greater than 40
percent for spondylolisthesis, grade II, with degenerative
disc disease of the lumbar spine prior to February 10, 2006
have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38
C.F.R. §§ 3.321, 4.1-4.7, 4.21, 4.40, 4.45, 4.71a, Diagnostic
Code 5243 (2006); 38 C.F.R. § 4.71a, Diagnostic Code 5293
(2002).
3. The criteria for a disability rating greater than 60
percent for spondylolisthesis, grade II, with degenerative
disc disease of the lumbar spine since February 10, 2006 have
not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38
C.F.R. §§ 3.321, 4.1-4.7, 4.21, 4.40, 4.45, 4.71a, Diagnostic
Code 5243 (2006); 38 C.F.R. § 4.71a, Diagnostic Code 5293
(2002).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
Disability Rating Greater than 20 Percent Prior to October
19, 2004
Disability ratings are determined by applying the criteria
set forth in VA's Schedule for Rating Disabilities, which is
based on the average impairment of earning capacity.
Individual disabilities are assigned separate diagnostic
codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1
(2006). If two evaluations are potentially applicable, the
higher evaluation will be assigned if the disability picture
more nearly approximates the criteria required for that
rating; otherwise, the lower rating will be assigned. 38
C.F.R. § 4.7. Reasonable doubt as to the degree of
disability will be resolved in the veteran's favor. 38
C.F.R. § 4.3.
Pertinent regulations do not require that all cases show all
findings specified by the Rating Schedule, but that findings
sufficiently characteristic to identify the disease and the
resulting disability and above all, coordination of rating
with impairment of function will be expected in all cases.
38 C.F.R. § 4.21. Therefore, the Board has considered the
potential application of various other provisions of the
regulations governing VA benefits, whether or not they were
raised by the veteran, as well as the entire history of the
veteran's disability in reaching its decision. Schafrath v.
Derwinski, 1 Vet. App. 589, 595 (1991).
The veteran's spondylolisthesis, grade II, with degenerative
disc disease of the lower spine is currently rated as 10
percent disabling from October 20, 1987 to January 24, 2000;
as 20 percent disabling from January 24, 2000 to October 19,
2004; as 40 percent disabling from May October 19, 2004 to
February 10, 2006; and as 60 percent disabling from February
10, 2006 to the present. During the pendency of the
veteran's appeal, VA promulgated new regulations for the
evaluation of intervertebral disc syndrome, 38 C.F.R. §
4.71a, Code 5293, effective September 23, 2002. See 67 Fed.
Reg. 54,345 (Aug. 22, 2002) (codified at 38 C.F.R. pt. 4).
Later, VA promulgated new regulations for the evaluation of
the remaining disabilities of the spine, effective September
26, 2003. See 68 Fed. Reg. 51,454 (Aug. 27, 2003) (codified
at 38 C.F.R. pt. 4). The amendments renumber the diagnostic
codes and create a general rating formula for rating diseases
and injuries of the spine, based largely on limitation or
loss of motion, as well as other symptoms. The Board notes
that the veteran's current 60 percent evaluation effective
February 10, 2006 is based upon the rating schedule in effect
prior to September 2002 under Code 5293.
If a law or regulation changes during the course of a claim
or an appeal, the version more favorable to the veteran will
apply, to the extent permitted by any stated effective date
in the amendment in question. 38 U.S.C.A. § 5110(g);
VAOPGCPREC 3-2000; see Kuzma v. Principi, 341 F.3d 1327 (Fed.
Cir. 2003); VAOPGCPREC 7-2003. Therefore, as each set of
amendments discussed above has a specified effective date
without provision for retroactive application, neither set of
amendments may be applied prior to its effective date. As of
those effective dates, the Board must apply whichever version
of the rating criteria is more favorable to the veteran.
The Board notes that the RO addressed both sets of amendments
in its February 2005 and May 2006 supplemental statement of
the case. Therefore, the Board may also consider these
amendments without first determining whether doing so will be
prejudicial to the veteran. Bernard v. Brown, 4 Vet. App.
384, 392-94 (1993).
The previous version of Code 5293 provides for a 20 percent
rating for intervertebral disc syndrome that is moderate with
recurring attacks. A 40 percent rating is assigned when the
disability is severe, with recurring attacks with
intermittent relief. A maximum evaluation of 60 percent is
in order for pronounced intervertebral disc syndrome, with
persistent symptoms compatible with sciatic neuropathy with
characteristic pain and demonstrable muscle spasm, absent
ankle jerk, or other neurological findings appropriate to the
site of the diseased disc. 38 C.F.R. § 4.71a, Code 5293 (in
effect prior to Sept. 23, 2002).
As amended, intervertebral disc syndrome is rated under Code
5243. 38 C.F.R. § 4.71a (2006). Under Code 5243,
intervertebral disc syndrome can be evaluated under either
the General Rating Formula for Diseases and Injuries of the
Spine or under the Formula for Rating Intervertebral Disc
Syndrome Based on Incapacitating Episodes, whichever method
results in the higher evaluation when all disabilities are
combined under 38 C.F.R. § 4.25.
According to the General Rating Formula for Diseases and
Injuries of the Spine, the disability is assessed with or
without symptoms such as pain (whether or not it radiates),
stiffness, or aching in the area of the spine affected by
residuals of injury or disease. In pertinent part, a 20
percent rating is assigned for disability of the
thoracolumbar spine when forward flexion is greater than 30
degrees but not greater than 60 degrees; or, the combined
range of motion is not greater than 120 degrees; or, there is
muscle spasm or guarding severe enough to result in an
abnormal gait or abnormal spinal contour such as scoliosis,
reversed lordosis, or abnormal kyphosis. A 40 percent rating
is awarded when forward flexion of the thoracolumbar spine is
30 degrees or less; or, when there is favorable ankylosis of
the entire thoracolumbar spine. If there is unfavorable
ankylosis of the entire thoracolumbar spine, a 50 percent
rating is in order.
Note (1) to the General Rating Formula for Diseases and
Injuries of the Spine states that any associated objective
neurologic abnormalities, including, but not limited to,
bowel or bladder impairment, will be evaluated separately,
under an appropriate diagnostic code. Note (2) sets forth
the normal ranges of motion for the spine for purposes of
disability evaluation.
The Formula for Rating Intervertebral Disc Syndrome Based on
Incapacitating Episodes provides for a 20 percent evaluation
for intervertebral disc syndrome with incapacitating episodes
having a total duration of at least 2 weeks but less than 4
weeks during the past 12 months. With incapacitating
episodes having a total duration of at least 4 weeks but less
than 6 weeks during the past 12 months, a 40 percent
evaluation is warranted. A maximum rating of 60 percent is
assigned with incapacitating episodes having a total duration
of at least 6 weeks during the past 12 months. Note (1)
defines an "incapacitating episode" as a period of acute
signs and symptoms due to intervertebral disc syndrome that
requires bed rest prescribed by a physician and treatment by
a physician.
When an evaluation of a disability is based on limitation of
motion, the Board must also consider, in conjunction with the
otherwise applicable diagnostic code, any additional
functional loss the veteran may have sustained by virtue of
other factors as described in 38 C.F.R. §§ 4.40 and 4.45.
DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors
include more or less movement than normal, weakened movement,
excess fatigability, incoordination, pain on movement,
swelling, and deformity or atrophy of disuse. VA has
determined that intervertebral disc syndrome involves loss of
range of motion. Therefore, 38 C.F.R. §§ 4.40 and 4.45 must
be considered when a disability is evaluated under Code 5293.
VAOPGCPREC 36-97.
Initially, the Board finds that the initial 20 percent
disability rating effective from October 20, 1987 to October
19, 2004 must be continued. As reflected in the November
1991 VA examination report, the veteran had fairly normal
range of motion of the lumbar spine, and there was no
objective indication of palpable tenderness in the
lumbosacral spine region and no sensory or motor deficit
noted. At that time, the veteran described frequent low back
pain and occasional right leg numbness, with pain increasing
with prolonged sitting or standing. In the May 2001 VA
examination report, the veteran had fairly normal range of
motion of the lumbar spine, although there was tenderness in
the left paravertebral area and over both sacroiliac joints.
The veteran also described back pain on a daily basis which
is aggravated by prolonged standing or sitting. Based on
this evidence, the Board cannot conclude that the overall
disability picture more closely approximated the severe
disability, with recurring attacks with intermittent relief,
needed for a 40 percent rating under Code 5293 prior to
October 19, 2004. 38 C.F.R. § 4.7.
The Board notes that applying the amended criteria of Code
5243 for the pertinent time period prior to October 19, 2004
does not yield a higher evaluation than the 20 percent
currently assigned. Specifically, when considering the
disability under the General Rating Formula for Diseases and
Injuries of the Spine, the evidence does not reflect
sufficient limitation of motion or ankylosis of the
thoracolumbar spine to warrant an increase. Similarly,
evaluation of the disability under the Formula for Rating
Intervertebral Disc Syndrome Based on Incapacitating Episodes
offers no opportunity for an increase. There has been no
reported period of acute signs and symptoms due to
intervertebral disc syndrome that require bed rest prescribed
by a physician and treatment by a physician to warrant a
rating greater than 20 percent prior to October 19, 2004. 38
C.F.R. § 4.7.
Disability Rating Greater than 40 Percent from
October 19, 2004 to February 10, 2006
Similarly, the Board finds that the 40 percent disability
rating effective from October 19, 2004 to February 10, 2006
must also be continued. Id. The October 19, 2004 VA
examination indicated that the veteran's range of motion was
limited, with forward flexion to 20 degrees, extension to 5
degrees, and rotation to 15 degrees in both directions. The
examiner noted that the veteran experiences daily pain with
numbness radiating into his right leg and foot and recurring
exacerbations about 2 to 3 times per week, consistent with
the criteria for a 40 percent evaluation. Id. However, there
continues to be no evidence of significant neurological
manifestations or evidence of spasm or other symptoms, such
that the overall disability picture does not more closely
approximate the criteria for a 60 percent rating until the
February 10, 2006 VA examination, where the veteran was
diagnosed with a severe limitation of motion characterized by
10 degrees of forward flexion, lateral bending, and lateral
rotation of the spine. Id. Based on this evidence, the Board
cannot conclude that the overall disability picture more
closely approximated the pronounced intervertebral disc
syndrome, with persistent symptoms compatible with sciatic
neuropathy with characteristic pain and demonstrable muscle
spasm, needed for a 60 percent rating under the previous
version of Code 5293 prior to February 10, 2006. 38 C.F.R. §
4.7.
The Board notes that applying the amended criteria of Code
5243 for the time period from October 19, 2004 to February
10, 2006 does not yield a higher evaluation than the 40
percent currently assigned. Specifically, when considering
the disability under the General Rating Formula for Diseases
and Injuries of the Spine, the evidence does not reflect
sufficient limitation of motion or ankylosis of the
thoracolumbar spine to warrant an increase. Similarly,
evaluation of the disability under the Formula for Rating
Intervertebral Disc Syndrome Based on Incapacitating Episodes
offers no opportunity for an increase. There has been no
reported period of acute signs and symptoms due to
intervertebral disc syndrome that require bed rest prescribed
by a physician and treatment by a physician to warrant a
rating greater than 40 percent from October 19, 2004 to
February 10, 2006. 38 C.F.R. § 4.7.
Disability Rating Greater than 60 Percent After February 10,
2006
The veteran's spondylolisthesis, grade II, with degenerative
disc disease of the lumbar spine is currently evaluated as 60
percent disabling under Code 5293, the maximum schedular
rating under that Code. However, the amended version of Code
5293 provides that intervertebral disc syndrome be evaluated
either on the total duration of incapacitating episodes over
the past 12 months or by combining under 38 C.F.R. § 4.25
separate evaluations of its chronic orthopedic and neurologic
manifestations along with evaluations for all other
disabilities, whichever method
results in the higher evaluation. "Chronic orthopedic and
neurologic manifestations" means orthopedic and neurologic
signs and symptoms resulting from intervertebral disc
syndrome that are present constantly, or nearly so. Note 2
indicates that chronic orthopedic and neurologic
manifestations should be rated separately under the most
appropriate diagnostic code. 67 Fed. Reg. at 54,349 (to be
codified at 38 C.F.R. pt. 4).
The Board notes that other diagnostic codes provide for a
rating greater than 60 percent. However, there is no
evidence of vertebral fracture, ankylosis of the spine, or
ankylosis of the lumbar spine to warrant consideration of
Codes 5285, 5286, or 5289, respectively. 38 C.F.R. § 4.71a
(2001); see Butts v. Brown, 5 Vet. App. 532 (1993) (choice of
diagnostic code should be upheld if supported by explanation
and evidence).
Under the amended criteria, intervertebral disc syndrome,
Code 5243, may be rated under either the General Rating
Formula for Diseases and Injuries of the Spine or under the
Formula for Rating Intervertebral Disc Syndrome Based on
Incapacitating Episodes. There is no higher rating than 60
percent under the criteria for disability of the lumbar
segment of the spine. Under the Formula for Rating
Intervertebral Disc Syndrome Based on Incapacitating
Episodes, the maximum schedular rating is 60 percent. 38
C.F.R. § 4.71a (2005).
Considering the evidence of record, the Board finds that the
overall disability picture does not more closely approximate
the criteria for a rating greater than 60 percent. 38 C.F.R.
§ 4.7. First, the February 2006 VA examination found no
evidence of unfavorable ankylosis of the lumbar spine; thus,
on the basis of limitation of motion alone, not more than a
40 percent rating could be assigned.
Considering the orthopedic and neurologic manifestations, the
VA examination report reflects limitation of motion of the
lumbar spine and additional medical records reflect findings
of sciatic pathology. Code 5292 provides for evaluations of
10, 20, and 40 percent for limitation of motion of the lumbar
spine that is slight, moderate, or severe, respectively. 38
C.F.R. § 4.71a. Examination in October 2004 reveals lumbar
spine forward flexion limited to 20 degrees and backward
extension limited to 5 degrees. The Board finds that these
results represent significant deviation from normal lumbar
spine motion that is most appropriately characterized as
severe, resolving doubt in the veteran's favor. 38 C.F.R. §
4.3. Therefore, a 40 percent rating is in order. As noted
previously, the current schedular criteria does not provide
for a rating in excess of 40 percent for limited motion of
the lumbar segment of the spine and there clearly is no
ankylosis present.
Disabilities of the peripheral nerves are evaluated under 38
C.F.R. § 4.124a based on findings of complete paralysis or
varying degrees of incomplete paralysis. This regulation
section specifies that the term "incomplete paralysis"
indicates a degree of lost or impaired function substantially
less than the type picture for complete paralysis given with
each nerve, whether due to varied level of the nerve lesion
or to partial regeneration. When the involvement is wholly
sensory, the rating should be for the mild, or at most, the
moderate degree. Under Code 8250, an 80 percent rating is
assigned when there is complete paralysis of the sciatic
nerve, the foot dangles and drops, no active movement is
possible of muscles below the knee, and flexion of the knee
weakened or (very rarely) lost. When there is incomplete
paralysis of the sciatic nerve, a 60 percent rating is in
order when disability is severe, with marked muscular
atrophy. Incomplete paralysis of the sciatic nerve that is
moderately severe, moderate, or mild, is assigned a 40, 20,
or 10 percent rating, respectively.
The veteran subjectively complains of numbness in his right
leg as well as periods of numbness of the entire right side
of his body (excluding the face). The October 2004 VA
examination report indicates that his right calf muscle is
mildly atrophic 11 inches at 8 inches below the knee while
the left calf is 12.5 inches. The report characterizes the
numbness as including the entire right leg encompassing upper
and lower roots, not fitting a radicular pattern. A February
2006 VA examination report revealed that deep tendon reflexes
in the arms and legs were 2+ and symmetrical and that there
was no weakness. There was no peripheral sensory loss or
sensory loss around the buttocks. Physical examination in
February 2006 reveals right leg straight leg raise testing to
be positive at 30 degrees. Given this evidence, the Board
cannot conclude that the overall disability picture from
sciatic nerve pathology warrants more than a 20 percent
rating. 38 C.F.R. § 4.7. Thus, combining the ratings
assigned for orthopedic and neurologic manifestations as
provided by Code 5293 would not result in a disability rating
greater than 60 percent since February 10, 2006. See 38
C.F.R. § 4.25 (combined ratings table).
As 60 percent is the maximum schedular rating under all other
applicable codes, the Board finds that the preponderance of
the evidence is against a disability rating greater than 60
percent for spondylolisthesis, grade II, with degenerative
disc disease of the lumbar spine after February 10, 2006. 38
C.F.R. § 4.3.
Finally, the Board finds no reason to refer the case to the
Compensation and Pension Service for consideration of an
extra-schedular evaluation under 38 C.F.R. § 3.321(b)(1).
That is, there is no evidence or allegation of exceptional or
unusual circumstances, such as frequent hospitalization or
marked interference with
employment, to suggest that the veteran is not adequately
compensated by the regular rating schedule. VAOPGCPREC 6-96.
The veteran is employed and only misses work approximately 6
days out of the year due to severe flare-ups. In summary,
the Board finds that the preponderance of the evidence is
against a disability rating in excess of 20 percent for
spondylolisthesis, grade II, with degenerative disc disease
of the lower spine prior to October 19, 2004 and or a rating
in excess of 40 percent prior to February 10, 2006.
The Duty to Notify and the Duty to Assist
Review of the claims folder reveals compliance with the duty
to notify. That is, by letters dated November 2002 and
September 2005, as well as the February 2005 supplemental
statement of the case, the RO advised the veteran of the
evidence needed to substantiate his claim and explained what
evidence it was obligated to obtain or to assist the veteran
in obtaining and what information or evidence the veteran was
responsible for providing. In addition, the February 2005
supplemental statement of the case includes the text of the
regulation that implements the notice and assistance
provisions from the statute.
Although the veteran was not informed by the RO to provide
all relevant evidence in his possession prior to the July
2001 rating decision in accordance with Pelegrini v.
Principi, 18 Vet. App. 112, 120-21 (2004), the veteran was
provided with such notice by letter dated September 2005.
Accordingly, the Board finds that the RO has provided all
required notice. 38 U.S.C.A. § 5103(a), 38 C.F.R.
§ 3.159(b)(1); see Quartuccio v. Principi, 16 Vet. App. 183
(2002).
During the pendency of this appeal, on March 3, 2006, the
Court issued a decision in the consolidated appeal of Dingess
v. Nicholson, 19 Vet. App. 473 (2006), which held that the
notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. §
3.159(b) apply to all five elements of a service connection
claim. Those five elements include: (1) veteran status; (2)
existence of a disability; (3) a connection between the
veteran's service and the disability; (4) degree of
disability; and (5) effective date of the disability. The
Court held that upon receipt of an application for a
service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R.
§ 3.159(b) require VA to review the information and the
evidence presented with the claim and to provide the claimant
with notice of what information and evidence not previously
provided, if any, will assist in substantiating or is
necessary to substantiate the elements of the claim as
reasonably contemplated by the application. Dingess, 19 Vet.
App. at 486. Additionally, this notice must include notice
that a disability rating and an effective date for the award
of benefits will be assigned if service connection is
awarded. Id.
In the present appeal, the veteran was notified of what type
of information and evidence was needed to substantiate his
claim for an increased rating and the requirements for
establishing an effective date for any award based on his
claim by letter dated August 2006 as well as in the April
2006 rating decision and May 2006 supplemental statement of
the case. The Board finds that any deficiency in the notice
to the appellant or the timing of these notices is harmless
error. See Overton v. Nicholson, No. 02-1814 (September 22,
2006) (finding that the Board erred by relying on various
post-decisional documents to conclude that adequate 38
U.S.C.A. § 5103(a) notice had been provided to the appellant,
the Court found that the evidence established that the
veteran was afforded a meaningful opportunity to participate
in the adjudication of his claims, and found that the error
was harmless, as the Board has done in this case).
With respect to the duty to assist, the RO has obtained the
veteran's service records, outpatient treatment records, and
multiple VA examinations. The veteran provided lay evidence
in the form of his own statements and testimony at his
September 2002 Board hearing. In a November 2005 statement,
the veteran indicated that he had no further medical evidence
to submit in support of his claim. The Board finds no
indication or allegation that additional pertinent evidence
remains outstanding. Therefore, the Board is satisfied that
the duty to assist has been met. 38 U.S.C.A. § 5103A.
ORDER
A disability rating for spondylolisthesis, grade II, with
degenerative disc disease of the lumbar spine greater than 20
percent prior to October 19, 2004 is denied.
A disability rating for spondylolisthesis, grade II, with
degenerative disc disease of the lumbar spine greater than 40
percent from October 19, 2004 to February 10, 2006 is denied.
A disability rating for spondylolisthesis, grade II, with
degenerative disc disease of the lumbar spine greater than 60
percent since February 10, 2006 is denied.
____________________________________________
C. W. SYMANSKI
Veterans Law Judge, Board of Veterans' Appeals
Department of Veterans Affairs